emsCharts Guide to NEMSIS v3 Updates Version 1

1 emsCharts NEMSIS v3 New Fields & Updates 3/26/2012 Page 1 of 14 emsCharts Guide to NEMSIS v3 Updates Version Contents Configuration / Required Fields / Sample Values .. 2 Page 1 Dispatch General .. 3 Page 1 Dispatch Referring/Receiving .. 3 Page 1 Times .. 3 Patient Information Patient .. 4 Patient Information PMHX/Meds/Allergies .. 4 Patient Information Employer .. 4 Patient Information Email .. 4 Patient Information Billing Information .. 4 Patient Information Neonatal .. 5 Patient Information CMS / Payment .. 5 Page 2 CC, SC, and HPI .. 6 Page 2 Impression/Diagnosis .. 6 Page 2 Chief Complaint .. 6 Page 2 Injury Details .. 6 Page 2 MVI Crash 7 Page 2 Cardiac Arrest.

2 8 Page 2 8 Page 2 Patient Movement .. 8 Page 3 Neuro/Airway .. 9 Page 4 Resp/Cardio .. 9 Page 5 Exams .. 9 Page 5 Drains, Obstetrics, Burns .. 9 Page 6 Labs, Imaging, Fluids .. 9 Page 7 PTA Meds/IV .. 9 Page 8 Activity Log / Vitals .. 9 emsCharts NEMSIS v3 New Fields & Updates 3/26/2012 Page 2 of 14 Page 8 New Procedures .. 10 Page 8 Procedures Airway & Intubation .. 10 Page 8 Procedures Intubation 10 Page 8 Procedures Decision .. 10 Page 8 Procedures - Hosp. 11 Patient Follow-up .. 11 Validations via Schematron .. 12 ICD-9 vs. ICD-10 Changes .. 12 Pertinent Negatives .. 14 Existing Fields with New Values .. 14 Configuration / Required Fields / Sample Values For the most part, all of these fields appear on the patient record and we do not have configuration options that turn them on/off.

3 Configuration options are slated to be put into place as they are requested and recommended by users. Some of the fields do have configuration options already. Below are the items that are configurable and the level of agency access that controls them: Date/Time: Dispatch Acknowledgement & Call Completed by Service Referring / Receiving: Mode Descriptors by Service Referring / Receiving: Hospital Designation by Service Pertinent Negatives by Service Patient: Last Oral Intake by Command Facility Page 2 CC/HPI: Other Complaints by Command Facility Page8 Intubation / Airway: Reasons for Failure by Command Facility Page 8 Intubation: Indications by Command Facility Patient: CMS fields by Service via existing billing configuration options.

4 Page 2 CC/HPI: Instructions Given determined by Command Facility mappings of Outcomes None of the new NEMSIS fields are required by regulatory bodies ( regions/states) at the time that this document was written; however certain fields may be required based on their grouping. For example, seat belt usage is not required, but in order to complete, you must select which seat you re talking about. Likewise, under Patient Information you can enter an email address, but you must select a type of email address: work or personal. emsCharts NEMSIS v3 New Fields & Updates 3/26/2012 Page 3 of 14 Lastly, for certain fields, Sample Values are provided. They are simplified versions of the NEMSIS values that appear in the chart.

5 Please reference the NEMSIS Data Dictionary for the entire list and full versions of the sample values. Page 1 Dispatch General New single select field: Ambulance Transport Code o Definition: Indicator about the type of transport of the patient. o Sample values: Initial Trip, Return Trip, Round Trip If Standby is selected as the Primary Type of Service, Standby Purpose becomes available. o Definition: The main reason the EMS Unit is on Standby as the Primary Type of Service for the EMS event. o Sample values: Disaster Event-Drill/Exercise, Fire Support-Rehab, Mass Gathering-Fair/Community Event, etc. Page 1 Dispatch Referring/Receiving New multi-select field under Referring Mode named Mode Descriptors o Definition: The documentation of transport mode techniques for this EMS response.

6 O Sample values: Intersection Navigation-Against Normal Light Patterns, Speed Normal Traffic New multi-select field under Receiving Mode named Mode Descriptors o Definition: The documentation of response mode techniques for this EMS response. o Sample values: Intersection Navigation-Against Normal Light Patterns, Speed Normal Traffic Referring Other Only (and Common Addresses) o . Max 15 characters. o Mile Post/Major Roadway . Max 35 characters. o Cross Street / Directions . Max 50 characters. o A single select field named COUNTRY to appear after County. Defaults to value in Service COUNTRY or US if blank. o Census Tract . This will contain 11 numbers in the standard census tract format.

7 emsCharts will research web service to auto-fill these results. However, NEMSIS has provided data files to load into the system for lookup. We have expanded Other address fields (address, city, state, county, zip, and the above) into EMS for better tracking of rendezvous locations . Receiving Hospital a new single select field named Designation o Definition: The designation associated with the hospital for this transport o Sample values: Behavioral Health, General, STEMI, Trauma Level I, etc. Page 1 Times New Date/Time field between Dispatch and En-route called Acknowledged . o Configuration read from Services Chart tab: Normal, Default Unused, Do Not Show o Definition: The date/time the dispatch was acknowledged by the EMS Unit.

8 emsCharts NEMSIS v3 New Fields & Updates 3/26/2012 Page 4 of 14 New Date/Time field between Leave Scene and Arrive Receiving called At Landing . o Air Units only o Definition: The date/time the Air Medical vehicle arrived at the destination landing area. New Date/Time field after In Quarters named Call Completed o Definition: The date/time the responding unit completed all tasks associated with the event including transfer of the patient, and such things as cleaning and restocking. Patient Information Patient On the main patient page underneath County is Census Tract . This field contains 11 numbers which represent the patient s Census Tract. Similar to the previously mentioned referring census tract.

9 For patients & relatives, a single select field COUNTRY o It will default to United States if blank. This new field (COUNTRY) renders International address checkbox useless, so it has been removed. Patient Information PMHX/Meds/Allergies New single date field: Last Oral Intake . Appears underneath Obtained above Current Medications . This captures the date/time of the last oral intake of any medication - not each medication. Patient Information Employer New single-select field under City/State/Zip named Country . Same as other country fields. Patient Information Email New button that opens a new window to enter patients email addresses and types. This field will contain the patient s email address pattern up to 100 characters.

10 The user can enter multiple emails and denote them as personal or work. Patient Information Billing Information New text field (with button) named Prior Authorization Payer : o Similar operation to Insurance Carrier field should allow for a custom entry, in text box but pressing the button pulls up a list of payers the patient has selected in the Billing Information company field. This should not be the full list of insurance carriers, but only the ones selected for that patient. o Definition: The Payer who has provided the Prior Authorization Code. New text field named Transport Authorization Code . Only 1 per chart. o String between 2 and 52 characters inclusive o Definition: Prior authorization code provided by the insurance carrier/payer.